PHILADELPHIA, PA – FAIRVIEW NURSING AND REHABILITATION CENTER

Based on review of facility policy, clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision to Resident R1 which resulted in actual harm to Resident R1 sustaining two fall incidents, requiring transfer to the hospital and [DIAGNOSES REDACTED].

Review of an investigation regarding the resident’s fall on (MONTH) 13, 2019, revealed that Resident R1  was found on the dining room floor after the resident was left unsupervised in the dining room by an activity aide (Employee E3).

Review of the witness statement for Employee E3 stated that when the employee returned, Resident R1 was on the floor lying on her right side next to her chair. Employee E3 notified nursing staff, and upon assessment by the nursing staff, the resident was noted with having a hematoma to the right temple (hematoma to the right temple- a localized swelling on the right side of the forehead that is filled with blood and caused by a break in the wall of a blood vessel) with a reddened area to the right shoulder. An x-ray was ordered by the physician and evidence of the right clavicular fracture (clavicular fracture- [MEDICAL CONDITION] collarbone, which is a long bone that lies between the shoulder blade and the breastbone) wasidentified. The resident was subsequently transported to the hospital on (MONTH) 13, 2019 and returned to the facility on (MONTH) 14, 2019 with a [DIAGNOSES REDACTED].

During an interview with Employee E4, Unit Manager, on (MONTH) 21, 2019 at approximately 3:10 p.m. regarding Resident R1’s fall on (MONTH) 13, 2019, Employee E4 was asked what the expectation was for activity staff when they were conducting activities with residents who may be a fall risk and they had to leave the room. Employee E4 reported that the expectation for staff was to not leave the residents in the room alone.

Review of facility documentation related to Resident R1’s unwitnessed fall on (MONTH) 2, 2019 revealed that the resident was found on the floor in the dining room at approximately 4:00 p.m. The resident was noted with a 0.5 x 0.5 cm abrasion on the right side of her face. Review of Resident R1’s nursing documentation revealed that on (MONTH) 7, 2019, the resident complained of leg pain and when assessed made facial grimaces whenever the resident was touched. Further review of the  resident’s clinical record revealed that an x-ray was completed at the facility on (MONTH) 8, 2019, and the resident was transferred and admitted to the hospital with [REDACTED].